“Psychotherapy as an adjunct to buprenorphine maintenance treatment is linked to a significant improvement in long-term treatment retention rates compared to standard counseling provided by prescribing physicians.

The findings contradict some studies that suggest that psychotherapy offers no benefit over standard counseling,

“Our observational study suggests that receipt of psychotherapy in the first year of buprenorphine treatment is associated with greater retention,” said first author Ajay Manhapra, MD, lead physician at the Advanced PACT Pain Clinic at Hampton VA Medical Center in Virginia.

The findings were presented here at the American Academy of Addiction Psychiatry (AAAP) 28th Annual Meeting.”

Imagine opioid treatment program (OTP) patients being able to get counseling and prescriptions from their own smartphone, while sitting in the comfort of their home. This is now reality for two OTPs operated by California-based Aegis Treatment Centers.

“We’ve been practicing telemedicine for three years in our Fresno and Delano clinics,” said Alex Dodd, Aegis CEO and president. These are all private-pay patients, either through insurance or by self-pay. And the program may expand to other clinics, thanks to funding from the Cures Act, Mr. Dodd told AT Forum.

The software used for telemedicine must be compliant with the Health Insurance Portability and Accountability Act (HIPAA), said Mr. Dodd. You can’t use Skype or Facebook, for example. Many psychotherapists already have such software, he added.

Admission and Buprenorphine Induction

Admitting patients for buprenorphine induction takes longer than admitting them for methadone induction, because more observation time is needed to make sure the patient’s condition is stable, said Mr. Dodd. So the first part of the admission process occurs face-to-face with the physician, who explains to the patient that some degree of withdrawal must occur before induction can begin. The next day, if the patient can’t come to the doctor, or if the doctor isn’t in the clinic, induction can be done by telehealth.

The physician begins the telehealth induction by calling the patient and conducting an interview about any symptoms the patient may be having. Via the screen, the physician can observe the patient for withdrawal symptoms. “This is one of those situations where experience really matters,” said Mr. Dodd. “If you are an experienced doctor who has seen hundreds if not thousands of patients, you can do this.”

Coming Soon: More Counseling by Telehealth

Currently, patients go to OTPs in Fresno or Delano for counseling. As California rolls out its hub-and-spoke Cures money, more counseling will take place by telehealth, said Mr. Dodd, who added, “I’m sure that in the next year or two we’ll be using telehealth for both admissions and counseling.”

The Fresno and Delano sites were chosen because the Aegis doctor most familiar with buprenorphine works with patients at those clinics.

But the most important part of treatment is not induction, said Mr. Dodd. “It’s the communication between the patient and the counselor.” He went on to quote Marc Lasher, MD, medical director of Aegis: “Medication is good, counseling is good, but medication and counseling together is the best.”

Regardless of which medication the patient is taking—methadone or buprenorphine—the patient is in a “stable, non-drug-seeking state,” said Mr. Dodd, “and is open and amenable to a dialogue.”

Bright Heart Health has received some of the Cures money to provide telemedicine to California patients with opioid use disorders, according to Mr. Dodd. “They will use telehealth extensively, doing everything others would do with bricks and mortar. They want to admit patients over telehealth, dispense medication through telehealth, and do counseling through telehealth.”

“Buprenorphine is one of the medications used to treat opioid addictions. A speaker at a recent medical conference in Anchorage said getting the medication to heroin users through their primary care providers is an essential way to reduce overdose deaths. But some addiction treatment professionals in Alaska say not so fast.

Martin spoke to a group of primary care providers from around Alaska during a conference in late April. He said that drug dependence needs to be looked at and treated like any other chronic disease — as part of primary care. And, just like medical providers don’t require counseling for medications to treat depression or diabetes, they shouldn’t require it for buprenorphine, a medication to treat addiction.

“I think it’s naive to think that counseling isn’t effective. I think that by just prescribing we’re addressing the biological effects of the individual and keeping them from suffering withdrawal symptoms,” Soderstrom said. “But we’re not addressing the root causes of the addiction and the underlying behavior that the individual is experiencing.”

“To Heaven Godley, a recovering heroin addict, the methadone treatment center he visits every day feels like home. “It’s my refuge,” said the 39-year-old Baltimore native.

Godley’s treatment plan at Reach Health Services, one of 20 opioid treatment centers in Baltimore that provide methadone and other addiction medications, is intensive. He talks to his behavioral health counselor several times a week, sees a psychologist to help manage his anger and gets regular medical checkups at an on-site clinic. The combination of medication and monthly or weekly counseling or group classes has been shown to be effective at keeping most patients away from heroin and other drugs for six months to a year.

But, like Godley, a small percentage of patients need counseling that is more intensive, said Reach’s medical director, Yngvild Olsen.

A growing consensus among medical researchers that patients who receive a combination of addiction medication and counseling that is tailored to their needs fare better than those who receive little or no counseling is leading to a change in policy in Maryland.”

“To Heaven Godley, a recovering heroin addict, the methadone treatment center he visits every day feels like home. “It’s my refuge,” said the 39-year-old Baltimore native.

Godley’s treatment plan at REACH Health Services, one of 20 opioid treatment centers in Baltimore that provides methadone and other addiction medications, is intensive. He talks to his behavioral health counselor several times a week, sees a psychologist to help manage his anger, and gets regular medical checkups at an on-site clinic.

To encourage the centers to offer more counseling when patients need it, Maryland’s Medicaid agency is changing the way it reimburses them. Rather than paying a flat rate for all patients, the federal-state health care program for the poor in March will begin to pay providers for as much counseling and related medical services as are needed for individual patients. At the same time, the state will lower its traditional per-person weekly reimbursement rate for opioid treatment centers.

The new fee structure is similar to schemes developed in New York and California. New Jersey is moving in the same direction. The shift reflects a growing consensus among medical researchers that patients who receive a combination of addiction medication and counseling fare better than those who receive only one or the other.”

Finding and keeping good counselors in an opioid treatment program (OTP) isn’t easy, no matter what state you’re in. Salaries need to keep pace with the high cost of living in metropolitan areas, where many OTPs are located—something that’s very difficult for many programs. But offering benefits such as training can help, especially when the workforce is self-selecting for passion for the field.

AT Forum looked at three states and three OTPs with different situations.

Colorado

In Colorado, regulatory requirements make finding counselors challenging, explained Tina Beckley, MA, CAC III, regional director for Colorado for Behavioral Health Group (BHG). While new OTPs are opening up in the state, many credentialed counselors didn’t renew their credentials.

For OTPs, 50% of the treatment staff must have either a level II or III certified addiction counselor credential (CACII or CACIII). But because the availability of CACII and CACIII counselors has gone down, OTPs in Colorado have had to offer those who remain more money, which they deserve, said Ms. Beckley. “It’s been very challenging for the program directors to find counselors,” she added, speaking not just for BHG.

For OTPs in general in Colorado, the annual salary for a CACII or a CACIII is up to about $40,000 having risen from about $30,000 15 years ago.

One way to find counselors is to look for interns at colleges and universities that offer drug and alcohol programs, where students working on a degree or a CAC credential need hours of clinical experience. “We are working on ramping up our internship program so we can offer those hours,” said Ms. Beckley.

Once an OTP finds a counselor, the next struggle is keeping the new employee. “Our metropolitan areas can be expensive to live in, so people tend to go where they get paid more,” she said. “If they can make a little more money by moving to another location, they do, so retention is challenging.”

However, counselors who work in OTPs “are passionate about our patients,” said Ms. Beckley. OTPs need to take advantage of this by supporting counselors, so they don’t burn out. When Medicaid started covering OTP treatment, the patient population became even more complex, with more needs. “We are now offering more clinical supervision.”

Many patients with Medicaid coverage have never before been in an OTP. “They’re coming in with more co-occurring conditions than we have seen,” said Ms. Beckley. This means counselors need to provide more referrals and a higher level of care. At BHG, OTPs are adding case management personnel and a special intake counselor to help with up-front work for new patients. “We work in a fast-paced environment, and demand a high level of functionality.”

Clinical supervision is essential to improve counselor retention and prevent burnout. One of the behavioral health organizations in Colorado requires participating OTPs to provide a half hour a week of individual supervision, and an additional hour per group setting, said Ms. Beckley. “That’s a lot of supervision, but counselors are benefitting from it.”

Washington State

Just this summer, Washington State’s arcane licensing requirements for the chemical dependency professional (CDP) certification were changed to make it easier for professionals to work as counselors. Under the old requirements, which have been contentious for more than a decade, a psychiatrist who had studied addiction medicine, or a licensed clinical psychologist whose area of expertise was addiction, had to go back to community college to get licensed as a CDP.

“The paraprofessionals had been fighting it,” said Molly Carney, PhD, MBA, executive director of Evergreen Treatment Services, of the change. “But now I’m happy to report that Washington State has entered the 21st century, and is finally able to license people who have expertise in other fields, like social work, psychology, and psychiatry.” This will give more people a chance to come into the field as counselors, she added.

Pay is another issue. “Just last week I informed my staff that we could increase salaries, but everybody was dissatisfied because it wasn’t enough,” she said. As in Colorado, the pressure for more money is most intense in urban areas. At Evergreen, all CDP salaries, whether at urban, small-town, or rural clinics, start at $39,000. Master’s degree salaries start at $42,000.

Evergreen also pays part of the fee for health insurance, with additional fees paid by the employees. Evergreen spends about $1,500 a month for a premium for medical and dental benefits. Employees pay an additional $900 a month for an individual plan; family coverage is more. “If I had the financial means, I’d cover their health insurance completely,” said Dr. Carney.

In Seattle, in the past year, Evergreen has had success in hiring new staff. “They move here from other areas, they like us, and sign on,” said Dr. Carney. “Where we get into trouble is our rural clinic, where we’ve had an extremely difficult time finding staff.”

To become a CDP, counselors need 1,500 supervised hours. They can get that experience in an OTP, which is very valuable. Washington State requires that the hours be in a formal accredited treatment program for substance use disorders, not in private practice.

This works to the benefit of OTPs, which tend to hire CDPs-in-training. “We get them through the number of hours they need, and then we keep them on,” said Dr. Carney. “We grow our own. It’s been a good model for us in the urban setting.”

But rural clinics are still a challenge. “The more remote, the bigger the challenge in terms of workforce,” said Dr. Carney. “We should be providing more telehealth services just for the counseling.”

Dr. Carney is a visible OTP director in the media, and she thinks this helps the counselors be “proud of the work they do, and who they work for.”

Dr. Carney made a four-minute video to convey the professionalism of the OTP field (https://www.youtube.com/watch?v=SqZy_AHwNtg). One of her medical directors is the previous president of the Washington Society for Addiction Medicine. This kind of connection is very helpful in attracting counselors to what society often views as an unrewarding profession. In fact, it’s extremely rewarding.

One of her counselors has been with Evergreen for only a year; she’s about 60 years old and had spent her entire pre-Evergreen career in drug-free treatment, adamantly opposed to methadone. Now that she sees how successful medication-assisted treatment with methadone is, she is “a believer,” said Dr. Carney. “Patients get stabilized and stay that way.”

But the bottom line is money—and not just for salaries. “It would be really useful to have funds for annual licensing fees, and for paying off student loans,” said Dr. Carney. “And to have dedicated funds to send my staff to training—they’re eager to learn, but I can’t afford to let them go.”

Rhode Island

The best situation we heard about for the OTP workforce came from the small state of Rhode Island. We talked with Linda Hurley, MA, president/CEO of CODAC Behavioral Healthcare, based in Cranston.

CODAC’s retention rate is “remarkable,” said Ms. Hurley, who has been with the OTP for 27 years. “Managers and executive staff have been with us for 20 years, and we have a core group of counselors, nurses, doctors, and administrative staff who stay with us.”

One reason for the high retention rate is that CODAC is “a mission-driven, non-profit” OTP, Ms. Hurley told AT Forum. “We don’t have to answer to certain profit goals, and can stick to our mission,” she said, adding that of course financial responsibility is also required. If the OTP’s rates are reimbursed well, and one year happens to have a particularly good margin, CODAC can put that money back into the care of patients. For example, the OTP had enough funding to integrate treatment for nicotine dependence into patient care.

The ability to provide high-quality treatment helps retain counselors and leaders, because of the particular personalities of those who seek work in this field, said Ms. Hurley. “They’re drawn to social service, but they also like science. They’re service- and mission-driven, and they know there’s no magic wand.”

Counselors also respond to training opportunities. At CODAC, training has been developed by creating core groups of expertise at each of its six sites. “So if a counselor has an interest in, for example, tobacco, or trauma, or EMDR [Eye Movement Desensitization and Reprocessing], or gambling, or mindfulness, pain management, psychiatric services, CODAC will pay for their training,” said Ms. Hurley.

This way, the organization will end up with 14 to 16 people agency-wide with expertise in a certain area. These experts can go on to train others in the agency, and be paid for their consulting work. “Our goal is to move to the train-the-trainer level of competency,” she said.

One specific area, motivational interviewing, is required training for everyone at CODAC—counselors, nurses, and administrative staff.

However, counselors also need to be paid adequately. And CODAC is no different from other OTPs, in that counselors will leave if they can get paid more elsewhere.

So CODAC takes the extra step of paying for licensure for counselors. “We have to do it or we’re going to lose them,” said Ms. Hurley.

CODAC also has a liberal leave program, and has, since its inception. “Good HR policies are the secret to retention, no matter what business you’re in,” she said. “When you’re sensitive and loyal to your employees, they’re sensitive and loyal back.”